Monday, June 6, 2016

Hospital, Birth Center or Home Birth? Part II

I am a bit wary of indulging in proffering my opinion in this virulent and vitriolic debate, considering that a) I do not have any medical background and b) my research on this subject has been tepid at best - I don’t have years to spend on a proper assessment. On the other hand, this is an opinion I need to make for my own upcoming delivery. Every woman should be entitled to a freedom of choice as to where and how she will deliver her baby. The issue is that most countries in the world do not provide the right infrastructure for a woman to effectively make her decision. The country may be too poor or too paternalistic - in one country, a woman is denied proper hospital care, and in the other, she is pushed into hospital with not much choice for midwifery care, whether through laws that make such care illegal or effectively difficult to obtain (for instance by not covering such care). It’s also pretty blatant that the pro-hospital/medical argument has a very paternalistic view and deems women’s choice to give birth at home or at a birth center stemming from the woman’s naïveté, or wish to be involved in the latest fashion (with home and birth center births increasing in the US) or from weighing their experiencing over risks. The women that want to give birth at home or at a birth center are thus fashioned in their paternalistic argument into children that need to be disciplined and brought into line - misogyny still at work. It is not considered that women that choose to give birth at home or at a birth center do not do so for vapid causes of fashion but because they believe that it would be a safer experience both for themselves and their baby. In fact, there are many good reasons for not going to a hospital, apart from the aim of having an “orgasmic” birth or a more pleasant experience. Hospitals are not run on the Hippocratic oath as much as on malpractice insurance. This is why your obstetrician may tell you that not one drop of alcohol is safe, for if they were to tell you a little is fine at times, or even more specifically that a glass of wine with dinner does not harm your baby - they may be responsible if you, now assured, do not quite understand what a “little” is or cannot measure your intake (which again views women as children that cannot control themselves and must be disciplined). Of course, not all obstetricians pander to this line. My OB late in my previous pregnancy when my blood pressure was rising, told me to work less, relax and have a glass of wine. We can go further and blame malpractice insurance on a defunct tort system and go even further and blame the existence of such a system on the lack of proper public healthcare and social net in the US (with patients forced to sue to recover their medical costs and economic losses), but that’s for another topic.

If we look at the fear of malpractice as the crux of hospital care, increased intervention - which is the main argument against hospital births- makes sense. Women will sue for injury to themselves and their child, but likely not for enduring a gruesome experience. After all, most women do not look forward to labour. If I could have my husband deliver - a fair swap considering I’ve had to carry the baby - I would. There is much literature exposing this view as stemming from the hospital experience which overcomplicates labor and turns it into a sterile, stressful and painful procedure rather than the miracle of birth. Some hospitals have a cut out time in which they induce women after natural labour is not progressing sufficiently or turn to caesarians (the etymology stemming from the fact that it was a law of the Roman Empire and therefore Caesar’s law, that no caesarean - known to cause maternal death - was to occur before the tenth month of pregnancy and only to save the baby when the mother’s life could not be saved). Much has been written on the “cascade” of intervention. For instance, induction causes much more painful labour, leading to likely requests for epidurals, which may necessitate more induction and a recursive pattern that may end up in a caesarian. The constant monitoring of women and their babies may be an obstruction as may be the cold unwelcome environment, from our natural mammalian instinct kicking in as well as obstructing movement, necessary to further labour. Women may want to squat or be on all fours to deliver and use gravity as an aid, but it is easier for obstetricians if women were sitting or laying down. All these interventions may lead to more tears and the environment of a hospital, albeit sterile, exposes women to an infection risk. There are other arguments too - labour is an intense physical exercise but in the hospital, women are only allowed ice chips and glucose in their IV lest they require general anesthetic. If a healthy woman with a normal pregnancy were to give birth and be able to do so in an uncomplicated way, the hospital may not be the right choice for her. The issue is that pregnancy and labour are akin to Russian roulette - it is hard to discern - particularly without ultrasounds and other exams that midwifery does not encourage - whether a woman and her baby are ready for a natural, uncomplicated pregnancy.

Home and birth center births are also not without complications and studies have shown that perinatal deaths are nearly double that of hospital births (for instance, in a recent study by the University of Oregon, albeit as one may expect, the midwifery camp disputes the findings). The one undisputed fact that both camps agree on is that if things go wrong at home or at a birth center, you must be transferred to hospital to save yourself and your baby. This begs the question of how quickly the midwifes would make this decision and how quickly you will be transferred to hospital care as well as how quickly they would assess you in hospital before they decide on a course of action. The midwifery camp discounts the importance of this fact by statistics - most pregnancies are fine and there is a low risk that something could go wrong. The stats of what happens when something goes wrong however are not so paraded.

Maybe understanding world statistics would aid us a little. According to the WHO, 813 women died every day in 2015 from pregnancy and labour related complications. Most of these deaths occurred in very low-resource countries (sub-Saharan Africa and South Asia) so we can safely assume that the “cascade of intervention” was not the cause of these maternal deaths. The WHO further states that a woman is 33 times more likely to die from pregnancy and labour complications in developing countries rather than developed countries. We should not be too quick to immediately assume that the main reasons for death, however, is lack of proper hospital/medical care. I would have liked to see the breakdown of these statistics to account for the health of women before pregnancy, for in the poorest countries in the world, general health is worse - and health before pregnancy is a determinative factor of how complicated the pregnancy and labour would be. Further, some of the countries with the highest maternal death rates are also countries in which children are giving birth, when their bodies are not yet developed enough to handle pregnancy and labour effectively.

So what about Europe and the United States? I’ve heard it touted that Europeans tend to give birth at home. This is patently incorrect according to facts from the European Parliament. Even the Dutch, which encourage home births, have only about a 1/3 of their births at home. Further, the Dutch have the highest - almost double - perinatal deaths in Europe. Most countries discourage home births (including France, Sweden and Germany) and some countries are neutral (Italy). Only Holland (and decreasingly so) and recently, Britain encourage home and birth center births. I am not sure where the myth of “French women give birth at home” came form (possibly because the French understand that cheese and wine are not going to kill you and your baby in pregnancy and may be quite good for you and your baby), but it’s not true. The United States has a pretty embarrassing record respecting maternal and infant mortality. Since 99.5% of births occur in the hospital, one might be quick to assume that this is the result of the “cascade of intervention” - if not for the fact that the United States has an embarrassing record of general healthcare. Women in the United States are generally more unhealthy when they become pregnant, which increases their complications during pregnancy and labour. Women are also older, increasing the risk of complications, but considering they are about the same average age as women in Europe, I would wager it’s pre-pregnancy health that may set the United State apart. If the United States had a good public healthcare system, this may not occur, but again, this is for another topic. Additionally, much has been written on the increase in maternal death rates in the United States over the past twelve or so years, but this is largely due to better information gathering due to changes in death certificates that require information as to whether the woman’s death occurred within 42 days or a year after childbirth. One thing I wonder regarding the maternal death rate statistics is whether a woman being transferred from a home or birth center birth going awry who dies in hospital is counted as a hospital death, being the place where she expired, or a home birth death? Showing that a woman was transferred would provide better statistics and reveal how well transferral in the event anything were to go wrong really is, for as both camps agree, if anything were to go wrong, transferral is the only option.

One thing to also consider is that midwifery may have knowledge and tricks that obstetricians lack and vice versa. So is the best best of both possible worlds to have a midwife with you in the hospital? This prevents any transferral problems in the case of an emergency. This does not however discount the fact that a birth center or your home may be more comfortable (and more familiar in the case of your home) than a hospital room. This also does not allow for the midwife to be in full control (particularly if she is not connected to the hospital). One thing we tend to forget in this argument is that as patients we have full rights to refuse treatment and prevent the “cascade of intervention”, so if the “cascade of intervention” were the cause of most hospital injury, it may make sense to simply refuse such intervention. Unfortunately, this is easier said than done - you are not your most cognisant self when enduring labour and while you may think your partner will stand up for you, your partner - whether they be a man or woman (albeit men I would wager would be more afraid) - seeing you in such distress, will most likely be more frightened than you and accept medical intervention.

Nevertheless, some hospitals are much more encouraging of a more “hands off” approach. My obstetrician has assured me that Kaiser in SF will allow me to not be immediately put on an IV, refuse constant monitoring, have me walk around and use my birth ball, get in the shower and tub etc At my incredulous raised eyebrow, she retorted “the west coast is much different from the east coast, you will see.” I was also told however that the person delivering my baby would most likely be a stranger as 40 OBs were on the roll. With my previous labour, I knew that it would be one of four OBs, and I had met all of them. This was an unwelcome new element, pushing me more to midwifery.

It seems the most neutral research would be on what the major causes of maternal and perinatal deaths are, how they occur and how they are assessed to be able to fully weigh in the risks of each option. The major causes of maternal death during childbirth are hemorrhage, hypertension and infection and the major causes of perinatal deaths appear to be trauma during childbirth (including the mother's hypertension, hemorrhage etc) and preterm labour. Which profession and location would be best equipped to prevent, assess these situations and handle them? Take hemorrhage for instance. This can be caused by uterine atony (ie exhaustion from a long labour) or rushed delivery of the placenta. Would you have a longer labour outside of hospital leading to uterine atony leading to hemorrhage and/or would obstetricians rush the placenta whereas midwives would take a more natural, slow approach? I'm not sure I'm even equipped to assess these highly medical evaluations. However, this would be the key to my opinion and I would need to do further research.

Another thing to consider is the price tag and location. For some fortunate women, this is not a concern, but for me, the dollar weighs in. I've heard that midwifery care is the least inexpensive option but for my circumstance in SF, it is the most expensive option. Knowing that second pregnancies may go much faster, I do not want to travel far to give birth to avoid having to give birth in a car or some other infection prone environment with no proper medical assistance. Home birth ticks the box here as does my hospital which is a mere 7 minutes walk away (albeit during labour and even my current third trimester waddle it may take a bit longer). I was elated to find out that SF - which surprisingly lacked a birth center- had one grand opening earlier in the year 10 mins walk from my house. It ticked the box of both being near my home and near my hospital. I was not expecting the $8k price tag however (with a hospital birth being $3200 out of pocket). I was also not too happy about the early discharge - within four hours of delivery - which in my case, meant four flights of stairs. I do like the ambience, the attentive approach - with natural pain management and help with positions, the flexibility and the post-natal care (up to three visits in the first week postpartum).

I'm still wary of the home birth option (I am risk averse and for the me the seriousness of the risk and not its risk factor weighed in to tip the scales) but having a midwife come to the hospital or going to the birth center seem very appealling. Unfortunately, before I could make my decision as to which option I would prefer, weighing in all factors, the universe seems to have made the decision for me. My due date comes at the worst possible time for the birth center and a midwife that came strongly recommended and does both home and hospital births. The former was full, in part because one midwife's wedding is on my due date and one other is going to her wedding, leaving only one midwife and two assistants in charge. After swallowing this refusal, I was yet refused by the midwife, who is away in July. I can continue to search for midwifes, albeit most midwifes will not provide care in hospitals.... there's no reason to give up yet, but not being sure of whether I really do want to deliver away from a hospital and the universe's nudges in this direction, it may well be where I end up. Albeit this time, I will be armed with more authority and more determination for a hands off approach.